To The Editor:

In the article, “Cementless total hip arthroplasty in patients with high congenital hip dislocation”(1) The authors are to be complimented for their classification of the different deformities and proposed management strategy for each. However,we are concerned about some of their surgical techniques.

Since 1999, we have used a proximally hydroxyapatite coated cementless stem; (Osteonics, Securfit Plus®) for these patients. Our surgical technique on the femoral side includes a short oblique subtrochanteric osteotomy and excision of a segment of femur sufficient to allow for a safe reduction. Safe reduction usually requires extensive soft tissue releases of the pelvifemoral muscles. The gluteus maximus, tensor fascia latae and adductors are routinely released, but we limit the extent of these releases as much as possible because preserving the attachment of the abductors and iliopsoas are important to optimize the functional outcome. We never resect or osteotomize the trochanters and, if a release is unavoidable, it is performed proximally. Thus, it is possible to preserve a complete segment of the proximal femur with a soft tissue envelope. This segment allows for better bone stock, prompt healing, reliable proximal fixation through the intact medial calcar, and avoids the complications of trochanteric osteotomy. With this technique we have not performed a femoral revision for any reason in 85 high dislocated hips since 1999.

In the current article(1), the authors prefer to resect the medial calcar with the lesser trochanter and they perform a greater trochanteric osteotomy. This approach destroys the proximal femur; thus distal fixation with a calcar replacement femoral stem remains the only option. Resecting the iliopsoas insertion and reattachment of the abductors may cause gait abnormalities and fixation failures. The reported femoral revision rate of 7% can be attributed to this technique.

We would ask the authors to comment on whether their technique results in deficiency of proximal bone support and motor power, as these may lead to limping, difficulty in stair climbing, early fixation failures and difficulty in performing subsequent revisions.

The author(s) of this letter to the editor did not receive payment or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author(s) are affiliated or associated.

Reference:

1. Eskelinen A, Helenius I, Remes V, Ylinen P, Tallroth K, Paavilainen T. Cementless total hip arthroplasty in patients with high congenital hip dislocation. J Bone Joint Surg Am 2006;88:80-91.