Is arthroplasty inevitable after Ilizarov hip reconstruction of unstable hip joints in adolescents and young adults? Long-Term Evaluation of 136 Cases

Introduction. Whereas hip joint destroying trauma and diseases are difficult situations, the problem is more complex when it is complicated by hip instability. This could be a sequel of several hip affections such as trauma, septic or tuberculous arthritis, neglected developmental dysplasia of the hip, postoperative conditions, and neurologic pathologies (cerebral palsy, myelomeningocele, poliomyelitis).

Purpose. The purpose of this study is to evaluate long-term radiographic and clinical outcomes of the Ilizarov hip reconstruction for the treatment of painful and unstable hips in adolescents and young adults.

Materials and methods. The study included 136 patients with an average age of 18.3 years (range, 6 to 34 years); 75 patients were males (55.1%) and 61 females (44.9%). The primary causes of the hip instability were untreated or unsuccessfully treated cases of septic arthritis (40 cases; 29.4 %), congenital hip dislocation (28 cases; 20.6 %), paralytic hip dislocation (36 cases; 26.5 %), proximal femoral focal deficiency (14 cases; 10.3 %), neglected fracture of the femoral neck (10 cases; 7.4 %), osteoarthritis (6 cases; 4.4 %), and tuberculous hip arthritis (2 cases; 1.5 %). The intervention consisted in the performance of two osteotomies (proximal and distal) of the femur with pelviс support and placement of the Ilizarov apparatus of a specific assembly.

Results. The external fixation period ranged from 4 to 12 months (6.5 months on average). Patients were followed up for an average of 17.4 years (range, 5 to 27 years). Multiple clinical parameters at final follow-ups showed significant improvement, including pain relief, pain-free walking distance, lameness, hip flexion and abduction, hip contracture, and lumbar lordosis. Functionally, the mean Harris Hip Score improved with a statistically significant difference from 48 points (range, 35–65) before surgery to 83 points (range 70–90) after surgery. The pain disappeared in all patients, with the exception of six cases of pain in the early postoperative period. In all cases, supportive walking aids were no longer necessary, with the exception of two cases of persistent pain by physical activities. Walking ability and painless walking distance improved in all patients from an average of 35 m (range, 10 to 50 m) before surgery to 1,150 m (range, 1,000 to 1,500 m) after surgery, showing significant difference.

Conclusion. Ilizarov pelvic support osteotomy provided a multi-purpose solution to the complex challenging problem of hip instability in adolescents and young adults with variable primary etiologies. The improvements in the hip motion, mechanical axis, and correction of limb-length discrepancy lead to good functional outcomes over a long-term follow-up. This treatment modality might avoid or postpone the need for total hip arthroplasty for several years.

1. Development of modified Ilizarov hip reconstruction surgery for hip dysfunction treatment in adolescent and young adults / S. Luo, L. Kong, J. Wang, H. Nie, B. Luan, G. Li // J. Orthop. Translat. 2020. Vol. 27. P. 90-95. DOI: 10.1016/j.jot.2020.11.002

2. El-Mowafi H. Outcome of pelvic support osteotomy with the Ilizarov method in the treatment of the unstable hip joint // Acta Orthop. Belg. 2005. Vol. 71, No 6. P. 686-691.

3. Umer M., Quadri T.A., Rashid R.H. Ilizarov hip reconstruction osteotomy - A review // Int. J. Surg. 2018. Vol. 54, Pt. B. P. 351-355. DOI: 10.1016/j.ijsu.2017.08.561

4. Pafilas D., Nayagam S. The pelvic support osteotomy: indications and preoperative planning // Strategies Trauma Limb Reconstr. 2008. Vol. 3, No 2. P. 83-92. DOI: 10.1007/s11751-008-0039-7

5. Inan M., Bowen R.J. A pelvic support osteotomy and femoral lengthening with monolateral fixator // Clin. Orthop. Relat. Res. 2005. Vol. 440. P. 192- 198. DOI: 10.1097/01.blo.0000180602.00487.47

6. Evaluation of the gluteus medius muscle after a pelvic support osteotomy to treat congenital dislocation of the hip / M. Inan, A. Alkan, A. Harma, K. Ertem // J. Bone Joint Surg. Am. 2005. Vol. 87, No 10. P. 2246-2252. DOI: 10.2106/JBJS.D.02727

7. Pelvic support osteotomy by Ilizarov's concept: Is it a valuable option in managing neglected hip problems in adolescents and young adults? / M.A. Mahran, M.A. Elgebeily, N.A. Ghaly, M.F.Thakeb, H.M. Hefny // StrategiesTrauma Limb Reconstr. 2011. Vol. 6, No 1. P. 13-20. DOI: 10.1007/s11751-011-0104-5

8. Pelvic support osteotomy for unstable hips using hybrid external fixator: case series and review of literature / A. Mandar, X.B. Tong, S.H. Song, Y.E. Park, J.H. Hong, H. Lee, H.R. Song // J. Orthop. Sci. 2012. Vol. 17, No 1. P. 9-17. DOI: 10.1007/s00776-011-0173-9

9. Krieg A.H., Lenze U., Hasler C.C. Ilizarov hip reconstruction without external fixation: a new technique // J. Child. Orthop. 2010. Vol. 4, No 3. P. 259-266. DOI: 10.1007/s11832-010-0256-8

10. Ilizarov hip reconstruction for the late sequelae of infantile hip infection / S.R. Rozbruch, D. Paley, A. Bhave, J.E. Herzenberg // J. Bone Joint Surg. Am. 2005. Vol. 87, No 5. P. 1007-1018. DOI: 10.2106/JBJS.C.00713

11. Pelvic support osteotomy (PSO): Indications, limits and complications / M. Catagni, F. Guerreschi, L. Lovisetti, H. Tsibidakis. In: Advanced Techniques in Limb Reconstruction Surgery. Ed. by Kocaoğlu M., Tsuchiya H., Eralp L. Heidelberg: Springer. 2015. P. 433-459. DOI: 10.1007/978- 3-642-55026-3_21

12. Ilizarov G.A. Hip dislocations. In: Transosseous osteosynthesis. Theoretical and clinical aspects of regeneration and growth of tissue. Ed. by Green S.A. Berlin, Heidelberg: Springer-Verlag. 1992. P. 701-726. DOI: 10.1007/978-3-642-84388-4

13. Илизаров Г.А., Самчуков М.Л. Реконструкция бедренной кости по Илизарову в лечении деформирующего артроза тазобедренного сустава // Ortop. Travmatol. Protez. 1988. No 6. P. 10-13.

14. Hardcastle P., Nade S. The significance of the Trendelenburg test // J. Bone Joint Surg. Br. 1985. Vol. 67, No 5. P. 741-746. DOI: 10.1302/0301-62 0X.67B5.4055873

15. Harris W.H. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation // J. Bone Joint Surg. Am. 1969. Vol. 51, No 4. P. 737-755.

16. Risk factors for revision of hip arthroplasties in patients younger than 30 years / J. Girard, C. Glorion, F. Bonnomet, D. Fron, H. Migaud // Clin. Orthop. Relat. Res. 2011. Vol. 469, No 4. P. 1141-1147. DOI: 10.1007/s11999-010-1669-x

17. An effective treatment for hip instabilities: pelvic support osteotomy and femoral lengthening / S. Gürsu, B. Demir, T. Yildirim, T. Er, A. Bursali, V. Sahin // Acta Orthop. Traumatol. Turc. 2011. Vol. 45, No 6. P. 437-445. DOI: 10.3944/AOTT.2011.2323

18. Ilizarov hip reconstruction in skeletally mature young patients with chronic unstable hip joints / K. Marimuthu, N. Joshi, C.S. Sharma, R. Bhargava, D.S. Meena, R.C. Bansiwal, R. Govindasamy // Arch. Orthop. Trauma Surg. 2011. Vol. 131, No 12. P. 1631-1637. DOI: 10.1007/s00402-011-1376-4

19. Pelvic Support Hip Reconstruction with Internal Devices: An Alternative to Ilizarov Hip Reconstruction / S. Metikala, B.T. Kurian, S.S. Madan, J.A. Fernandes // Strategies Trauma Limb Reconstr. 2020. Vol. 15, No 1. P. 34-40. DOI: 10.5005/jp-journals-10080-1450

20. The Pelvic Support Osteotomy After Type IVA Septic Arthritis of the Hip / C. Bytyqi, F. Morina, N. Salihaj, H. Qorraj, D. Bytyqi, B. Shabani // Med. Arch. 2014. Vol. 68, No 6. P. 422-423. DOI: 10.5455/medarh.2014.68.422-423

21. Reynders-Frederix P., Reynders-Frederix C., Wajid M. Pelvic Support Osteotomy; Salvage Procedure in Chronically Dislocated Hips Case Report: Technical Note on the On-lay Bone Positioning of a Lengthening Nail and Review of the Literature // Open Orthop. J. 2016. Vol. 10. P. 232-240. DOI: 10.2174/1874325001610010232

22. Alrabai H.M., Gesheff M.G., Conway J.D. Use of internal lengthening nails in post-traumatic sequelae // Int. Orthop. 2017. Vol. 41, No 9. P. 1915- 1923. DOI: 10.1007/s00264-017-3466-6

23. Milch H. The resection-angulation operation for hip-joint disabilities // J. Bone Joint Surg. Am. 1955. Vol. 37-A, No 4. P. 699-717.

24. Pontes M.D.S., Bortolin P.H., Volpon J.B. Double femoral osteotomy for the treatment of severe sequelae of the immature hip // Acta Ortop. Bras. 2020. Vol. 28, No 6. P. 287-290. DOI: 10.1590/1413-785220202806234170

25. Late results after subtrochanteric angulation osteotomy in young patients / M. Schiltenwolf, C. Carstens, L. Bernd, M. Lukoschek // J. Pediatr. Orthop. B. 1996. Vol. 5, No 4. P. 259-267.

26. Milch H. The postosteotomy angle // J. Bone Joint Surg. Am. 1944. Vol. 26. P. 394-400.

27. Recurrent dislocations and complete necrosis: the role of pelvic support osteotomy / I.H. Choi, T.J. Cho, W.J. Yoo, C.H. Shin // J. Pediatr. Orthop. 2013. Vol. 33, No Suppl. 1. P. S45-S55. DOI: 10.1097/BPO.0b013e318281216b

28. Thabet A.M., Catagni M.A., Guerreschi F. Total hip replacement fifteen years after pelvic support osteotomy (PSO): a case report and review of the literature // Musculoskelet. Surg. 2012. Vol. 96, No 2. P. 141-147. DOI: 10.1007/s12306-011-0178-8